Atrial fibrillation

Red Flags

Haemodynamically unstable AF (hypotension, ischaemic chest pain, acute heart failure) — emergency electrical cardioversion^[1]
AF with pre-excitation (WPW pattern) and rapid ventricular response — avoid AV-node blockers; use procainamide or DC cardioversion^[1]
New ischaemic stroke or TIA in patient with AF — start anticoagulation per timing guidance after exclusion of haemorrhage^[1]
AF with valvular heart disease (moderate-to-severe mitral stenosis or mechanical valve) — DOACs contraindicated; warfarin only^[1]

Catheter ablation (pulmonary vein isolation)^[1]
Offer for symptomatic paroxysmal or persistent AF where drug treatment unsuccessful, not tolerated, or declined; first-line option for some symptomatic patients per shared decision making
Left atrial appendage occlusion (LAAO)^[1]
Consider if AF with high stroke risk and contraindication to long-term anticoagulation

Drug	Class	Adult	Paediatric	Notes
Apixaban^[1]	DOAC (factor Xa inhibitor)	5 mg PO BD; reduce to 2.5 mg BD if any 2 of: age ≥80, weight ≤60 kg, creatinine ≥133 µmol/L	—	DOAC preferred over warfarin in non-valvular AF per NICE 2021 update
Edoxaban^[1]	DOAC (factor Xa inhibitor)	60 mg PO once daily; 30 mg if eGFR 15–50, weight ≤60 kg, or concomitant ciclosporin/dronedarone/erythromycin/ketoconazole	—	Once-daily alternative DOAC
Warfarin^[1]	Vitamin K antagonist	Titrate to INR 2–3 (mechanical mitral valve: 2.5–3.5)	—	First-line in moderate–severe mitral stenosis or mechanical valves where DOACs contraindicated
Bisoprolol^[1]	Beta-blocker (cardioselective)	2.5–10 mg PO once daily; titrate to resting heart rate <110 (lenient) or <80 (strict if symptomatic)	—	First-line rate control. Atenolol or metoprolol succinate are alternatives
Diltiazem^[1]	Non-DHP calcium channel blocker	120–360 mg PO daily (sustained-release)	—	Rate control alternative when beta-blockers contraindicated. AVOID in HFrEF
Flecainide^[1]	Class IC antiarrhythmic	50–150 mg PO BD; 'pill-in-pocket' 200–300 mg single dose for selected paroxysmal AF without structural heart disease	—	Rhythm control in structurally normal heart; contraindicated with ischaemic or structural heart disease

Apixaban^[1]

DOAC (factor Xa inhibitor)

Adult: 5 mg PO BD; reduce to 2.5 mg BD if any 2 of: age ≥80, weight ≤60 kg, creatinine ≥133 µmol/L
Paediatric: —

DOAC preferred over warfarin in non-valvular AF per NICE 2021 update

Edoxaban^[1]

DOAC (factor Xa inhibitor)

Adult: 60 mg PO once daily; 30 mg if eGFR 15–50, weight ≤60 kg, or concomitant ciclosporin/dronedarone/erythromycin/ketoconazole
Paediatric: —

Once-daily alternative DOAC

Warfarin^[1]

Vitamin K antagonist

First-line in moderate–severe mitral stenosis or mechanical valves where DOACs contraindicated

Bisoprolol^[1]

Beta-blocker (cardioselective)

Adult: 2.5–10 mg PO once daily; titrate to resting heart rate <110 (lenient) or <80 (strict if symptomatic)
Paediatric: —

First-line rate control. Atenolol or metoprolol succinate are alternatives

Diltiazem^[1]

Non-DHP calcium channel blocker

Rate control alternative when beta-blockers contraindicated. AVOID in HFrEF

Flecainide^[1]

Class IC antiarrhythmic

Adult: 50–150 mg PO BD; 'pill-in-pocket' 200–300 mg single dose for selected paroxysmal AF without structural heart disease
Paediatric: —

Rhythm control in structurally normal heart; contraindicated with ischaemic or structural heart disease

Take anticoagulation every day at the same time — missing doses sharply raises stroke risk; never stop without medical advice^[1]
Sudden weakness on one side, slurred speech, severe headache, or vision changes — call emergency services immediately (possible stroke)^[1]
Watch for unusual bruising, prolonged bleeding, black stools, or bloody urine — contact your clinician promptly^[1]

Haemodynamically unstable AF (hypotension, ischaemic chest pain, acute heart failure)Emergency department for synchronised electrical cardioversion^[1]
Symptomatic paroxysmal AF despite rate or rhythm-control drug therapyCardiology / electrophysiology for catheter ablation evaluation^[1]
AF with high stroke risk and contraindication to anticoagulationCardiology / electrophysiology for LAAO evaluation^[1]
Suspected AF with no rhythm capture on standard ECG despite symptomsCardiology for extended ambulatory monitoring or implantable loop recorder^[1]

Diagnosis, stroke prevention, and rate/rhythm control of atrial fibrillation in adults, with primary-care-focused decision support.

1.NICE NG196 Atrial fibrillation: diagnosis and management (April 2021, August 2023 update) (2023)